ACEP and Its New York Chapter Take Issue With Blue Cross/Blue Shield Report That Is Based on Misleading Data

Health Plans Historically Have Denied Coverage for Emergency Care

WASHINGTON, May 27 /PRNewswire-USNewswire/ -- The American College of Emergency Physicians (ACEP) and New York ACEP today took issue with a report released by Excellus Blue Cross/Blue Shield about emergency care in upstate New York.  Saying the report is based on a method developed by the New York University's Center for Health and Public Service Research, Dr. Sandra Schneider of Rochester, New York, and president-elect of ACEP, said it does not capture all the data necessary to analyze whether an emergency visit was appropriate, and it leads to false conclusions.

"It's ironic that a health plan would release this report right after Congress enacted health care reforms that apply the prudent layperson standard to all health plans," said Dr Schneider.  "Health plans historically have denied coverage for emergency care, which is why this standard is needed.  The nation's emergency physicians have fought hard for many years to make sure health plans do not deny coverage for emergency care, for example, when they have the symptoms of a medical emergency, such as chest pain, but after examination, it is determined they have a hiatal hernia (nonurgent medical condition) and not a heart attack."  Emergency physicians have always advocated that nothing should prevent patients who believe they are experiencing a medical emergency from seeking immediate care at an emergency department, whether or not the ultimate diagnosis and treatment is for a non-life-threatening condition.  

New York ACEP in April 2010 sent a letter to the New York State Department of Health expressing concerns about how the method relies on diagnosis at discharge, which does not reflect the potential severity and acuity of a visit.  The chapter said the method has never been reviewed or tested for validity by any outside groups or peer review, which is a basic tenet of research validation.   It also contradicts earlier studies conducted by the state health department and New York ACEP.

"There are serious and profound methodological flaws in the Excellus study," said Dr. Gerard Brogan, president of the New York ACEP. "Using the final discharge diagnosis rather than the presenting symptoms, ignoring that the patient with low back pain could have just as easily had a rupturing aortic aneurysm, as well eliminating all the patients that were admitted to the hospital from the ER due to the severity of their illness, unfortunately significantly weakens this analysis and calls into question its validity."

The report defines nonurgent care as any patient who could wait at least 12 hours for treatment — unlike the CDC, which defines nonurgent care as anyone who could wait 24 hours for treatment.  Patients should not be in the position of diagnosing their own medical conditions.  

"Emergency care represents less than 3 percent of the nation's $2.1 trillion in health care expenditures while caring for 120 million visits a year," said Dr. Angela Gardner, president of ACEP.  "Emergency physicians expect ER visits to increase with health care reform, due to growing physician shortages."

The American College of Emergency Physicians has worked for more than 17 years for a passage of a national "prudent layperson" standard, to require health insurance plans to base coverage of emergency care on a patient's symptoms, not the final diagnosis, which more accurately reflects the resources, time and expertise used to diagnose and treat these patients.

ACEP is a national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.  

SOURCE American College of Emergency Physicians